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Primum non nocere

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Bernice Clark |
Unnecessary proceduresAccording to CDC, 2.5 million unnecessary procedures are performed annually in the US only. Although it may seem a big number, it's just 5.2% of 48 million surgical procedures in total.


As we know there are two sides to every coin and medical science is not mathematics and finding the right solution for the problem is not always a straightforward process. Add to that different approaches to the problem and it's easy to see why sometimes the patient undergoes an unnecessary procedure: sometimes the procedure just seems the right way to go.

Take, for example, prostate cancer. The higher a man's prostate-specific antigen (PSA), the higher the risk of prostate cancer. As a rule of thumb PSA higher than 4 is considered dangerous. On the other hand, there are men with a higher PSA who never develop cancer.

So, when a doctor has a patient with a high PSA, he has two choices: to perform the surgery or do nothing. There's no doctor that will gamble with patient's life and her/his career choosing to wait hoping for the best. That also stands true for the results of mammography which is often misdiagnosed and the best way to go is to ask for a second opinion.

True, sometimes it's about the money. Statistics shows that poor women will probably have a mastectomy (breast removal) and not a lumpectomy (removal of the cancer but not the breast) because it's cheaper to remove a breast. If the doctor can earn more money from the surgery than from non-invasive treatment, there is a greater chance that the surgery will be advised. Always ask for a second opinion.

The combination of running for the money and speed in order to solve the problem fast is another reason for unnecessary procedures. This is the case, for example, with surgery for weight loss, in almost every case an unnecessary procedure with arguable results, with the only goal to make the patient temporarily happy and her/his doctor's pocket full.

So, ethics plays an important role, too. There are women with a genetic predisposition for breast cancer and they want their breasts to be removed. Although nobody can claim for sure that the cancer will develop, a doctor may respect patient's wish and perform unnecessary mastectomy.

In this case we are talking about surgery on a healthy person which certainly doesn't follow Primum non nocere - "First, do no harm", and it's about the patient who needs to be educated. Breast cancer spreads in three different ways: through the lymph system (the most common way), through the blood or through tissue. So, if it's meant to be, the money is spent in vain.

A study shows that if a doctor was trained before 1981, the woman is much more likely to have a mastectomy although lumpectomy are as safe as a mastectomy for most early stage disease. So, constant medical education is the way toward preventing unnecessary surgeries.

Coronary angioplasty is a procedure that saves lives after a heart attack but if the patient has a stable heart disease there is other way: the right combination of medications may work very well and may prevent heart attack and prolong life - all that without a single cut.

Also, studies show that coronary bypass surgeries provide only temporary relief and that new techniques bring more benefits with a smaller risk. It's on the doctor to decide which way to go, and sometimes he must do that fast.

Caesarean section, in its nature an emergency procedure when giving birth, is the most common major surgery. More and more women want that procedure because they want their baby arrive on the exact date when all family can be in the hospital. Others ask for it because of fear of labor and childbirth, and that's especially true for first-time mothers. There's no such thing as a routine surgical procedure because every opening is a potentially life-threatening procedure.

Surgical procedures can be the fastest way to the solution but doctors must think is the fastest way the best for the patient. Patients, on the other hand, should always ask for a second opinion - and they must have patience. It's always better to spend a month on healing in conservative way than to choose "open-cut-goodbye" approach. Body is like Pandora's box: it's best when it's unopened.

Contributed by: C. A. V. Nogueira, M.D., Abraham Eisenstein, M.D.

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